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Direct Deposit Authorization Form

RXGO Enterprises LLC DBA RxGo
9457 S. University Blvd., Ste 923, Highlands Ranch, CO 80126
(720) 983-0575

Name on Account:
Mailing Address:
City, State, Zip:
Name of Bank:
Account #:
9-Digit Routing #:
Type of Account:

Upload a voided check below for the account to which funds should be deposited. If a void check is not uploaded we cannot be responsible if the account or routing number is entered incorrectly (Photo or Scan is fine)

I confirm that RXGO Enterprises LLC DBA RxGo is hereby authorized to directly deposit my payment/s to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Partner's Signature

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

10/26/2020 11:19 AM MDT

Direct Deposit Authorization Form Uploaded by Mike Spivey - mike.spivey@outlook.com IP 174.16.139.84